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CLEANINGS & PREVENTION
Simple Tooth Extractions
Dental X Rays
Panoramic X Rays
Dental Exams Cleanings
Digital X Rays
Fluoride Treatment
Home Care
How To Properly Brush Floss
Oral Hygiene Aids
Sealants
Cosmetic Dentistry
Dental Implants
Procera® Crowns
Composite Fillings
Porcelain Crowns Caps
Porcelain Veneers
Teeth Whitening
Periodontal Disease
What is Periodontal Gum Disease
Diagnosis
Treatment
Maintenance
Causes of Periodontal Disease
Types of Periodontal Disease
Signs Symptoms of Periodontal Disease
Mouth Body Connection
Periodontal Disease and Diabetes
Periodontal Disease Heart Disease and Stroke
Periodontal Disease and Pregnancy
Periodontal Disease and Osteoporosis
Periodontal Disease and Respiratory Disease
Restorations
Dentures Partial Dentures
Empress® Restorations
Fixed Bridges
Inlay Restorations
Onlay Restorations
Oral & Maxillofacial Surgery
Botox® as an Alternative Treatment For Tmj
Sleep Apnea
Sleep Apnea Appliances
Endodontics
Cracked Tooth
Dental Anxiety and Fear
Dental Emergencies
Orthodontics
Invisalign®
What is Orthodontics
What is an Orthodontist
What is a Malocclusion
Who Can Benefit From Orthodontics
Why Straighten Teeth
Orthodontic Dictionary
Periodontics
What is a Periodontist
When to See a Periodontist
Antibiotic Treatment
Bruxism
Crown Lengthening
Gum Recession
Oral Cancer Exam
Periodontal Scaling & Root Planing
Pocket Irrigation
Prophylaxis (Teeth Cleaning)
Prosthodontics
Crowns (Caps)
Dental Implants | Prosthodontics
Dentures & Partial Dentures
Pediatric Dentistry
Baby Bottle Tooth Decay
Care For Your Child’s Teeth
Dental Emergencies
Dental Emergencies | Pediatric
Dental Radiographs (X-Rays)
Does Your Child Grind His or Her Teeth at Night
Eruption of Your Child’s Teeth
First Visit
Fluoride
Good Diet
How Often Should Children Have Dental Checkups?
How to Prevent Cavities
Mouth Guards
Pacifiers and Thumb Sucking
Pediatric Dental Appliances
Perinatal and Infant Oral Health
Sealing Out Tooth Decay
Sippy Cups
Tongue Piercing
What is Pulp Therapy?
What’s The Best Toothpaste For my Child?
When Should Children Have Their First Dental Visit?
When Will my Baby Start Getting Teeth?
Why are Primary Teeth Important?
Why See a Pediatric Dentist?
Surgical Instructions
After Tooth Extractions
Wisdom Tooth Extraction
Dental Sedation
Root Canal Therapy
TMJ Disorder Treatment
Our Blog
New Patient Form
Reviews
Contact Us
COVID-19 Forms
STAFF CONSENT
PATIENT CONSENT
Home
Our Dentist
Our Services
CLEANINGS & PREVENTION
Simple Tooth Extractions
Dental X Rays
Oral Cancer Exam
Panoramic X Rays
Dental Exams Cleanings
Digital X Rays
Fluoride Treatment
Home Care
How To Properly Brush Floss
Oral Hygiene Aids
Sealants
Cosmetic Dentistry
Dental Implants
Procera® Crowns
Composite Fillings
Porcelain Crowns Caps
Porcelain Veneers
Teeth Whitening
Periodontal Disease
What is Periodontal Gum Disease
Diagnosis
Treatment
Maintenance
Causes of Periodontal Disease
Types of Periodontal Disease
Signs Symptoms of Periodontal Disease
Mouth Body Connection
Periodontal Disease and Diabetes
Periodontal Disease Heart Disease and Stroke
Periodontal Disease and Pregnancy
Periodontal Disease and Osteoporosis
Periodontal Disease and Respiratory Disease
Restorations
Dentures Partial Dentures
Empress® Restorations
Fixed Bridges
Inlay Restorations
Onlay Restorations
Oral & Maxillofacial Surgery
Botox® as an Alternative Treatment For Tmj
Sleep Apnea
Sleep Apnea Appliances
Endodontics
Cracked Tooth
Dental Anxiety and Fear
Dental Emergencies
Orthodontics
Invisalign®
What is Orthodontics
What is an Orthodontist
What is a Malocclusion
Who Can Benefit From Orthodontics
Why Straighten Teeth
Orthodontic Dictionary
Periodontics
What is a Periodontist
When to See a Periodontist
Antibiotic Treatment
Bruxism
Crown Lengthening
Gum Recession
Oral Cancer Exam
Periodontal Scaling & Root Planing
Pocket Irrigation
Prophylaxis (Teeth Cleaning)
Prosthodontics
Crowns (Caps)
Dental Implants
Dentures & Partial Dentures
Fixed Bridges
Porcelain Veneers
Pediatric Dentistry
Baby Bottle Tooth Decay
Care For Your Child’s Teeth
Dental Emergencies
Dental Emergencies
Dental Radiographs (X-Rays)
Does Your Child Grind His or Her Teeth at Night
Eruption of Your Child’s Teeth
First Visit
Fluoride
Good Diet
How Often Should Children Have Dental Checkups?
How to Prevent Cavities
Mouth Guards
Pacifiers and Thumb Sucking
Pediatric Dental Appliances
Perinatal and Infant Oral Health
Sealing Out Tooth Decay
Sippy Cups
Tongue Piercing
What is Pulp Therapy?
What’s The Best Toothpaste For my Child?
When Should Children Have Their First Dental Visit?
When Will my Baby Start Getting Teeth?
Why are Primary Teeth Important?
Why See a Pediatric Dentist?
Surgical Instructions
After Tooth Extractions
Wisdom Tooth Extraction
Dental Sedation
Root Canal Therapy
TMJ Disorder Treatment
Our Blog
Reviews
Contact Us
COVID-19 Forms
STAFF CONSENT
PATIENT CONSENT
COVID-19 Pandemic Dental Treatment Consent Form
Patient First Name:
Patient Last Name:
CMOH Order
05-2020
legally obligates any person who has the following cough, fever, shortness of breath, runny nose, or sore throat (that is not related to a pre-existing illness or health condition) to be in isolation (quarantine) for 10 days from the start of symptoms, or until symptoms resolve, whichever takes longer. If they are exhibiting any of these symptoms, it is suggested they complete the
COVID-19 Self-Assessment online tool
to determine if they should be tested.
Yes
No
I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.
Yes
No
I understand that due to the frequency of visits of other dental patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in a dental office.
Please check off each box
to indicate
"I DO NOT"
have the following symptoms of COVID-19 as identified by Alberta Health Services:
SYMPTOMS
Yes
No
Fever > 38°C
Yes
No
New cough or worsening chronic cough
Yes
No
Sore throat or painful swallowing
Yes
No
New or worsening shortness of breath
Yes
No
Difficulty Breathing
Yes
No
Flu-like symptoms
Yes
No
Runny Nose
PLEASE ALSO CHECK OFF EACH OF THESE BOXES TO CONFIRM THE FOLLOWING STATEMENTS ARE TRUE.
*Note: If you cannot confirm the statement as true, please leave the box blank.
Yes
No
I confirm I know that there are categories of people who are considered to be high risk. I understand the high risk category factors are being 65 years of age or older, heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder.
High Risk & Exposure
Yes
No
I fall into the following high risk categories
and my dentist and I have discussed the risks, and I have agreed to proceed with treatment.
Yes
No
I confirm that to my knowledge I am not currently positive for the novel coronavirus.
Yes
No
I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus.
Travel Outside of Canada
Yes
No
I verify that I have not returned to Alberta from any country outside of Canada whether by car, air, bus, boat or train in the past 14 days.
Yes
No
I understand that any travel from any country outside of Canada, including travel by car, air, bus, boat or train, significantly increases my risk of contracting and transmitting the novel coronavirus. Alberta Health Services require self-isolation for 14 days from the date a person has returned to Canada.
Physical Distancing
Yes
No
I understand that Alberta Health Services has asked individuals to maintain physical distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment.
Close Contact
Yes
No
I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by Alberta Health, the Communicable Disease Control or any other governmental health agency.
OR
Yes
No
I verify that I am a healthcare worker who has worn appropriate PPE.
LIST OF DENTAL TREATMENT
I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above listed dental treatment completed during the COVID-19 pandemic.
SIGNATURE OF PATIENT
Printed Name
Date
(YYYY-MM-DD)
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